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This is an application for cash, health care and the Supplemental Nutrition Assistance Program (SNAP) benefits. If you need this application in another language or someone to interpret, please contact
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Here is how to fill out health care sanctuaries:
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Begin by gathering all the necessary information that will be required to fill out the form, such as personal details, medical history, and contact information.
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Make sure to carefully read the instructions provided with the form to understand what is required in each section.
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Start by filling out the basic personal details like name, date of birth, address, and social security number.
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Progress to the section where you will need to provide information about your medical history. Be honest and provide accurate information to the best of your knowledge.
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Who needs health care sanctuaries?

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Health care sanctuaries are needed by individuals who require medical assistance or support in a safe and protected environment.
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Those who may need health care sanctuaries include:
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- Individuals with chronic and complex medical conditions
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- Elderly individuals who need specialized care and supervision
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- Individuals recovering from surgery or major medical procedures
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- Patients with mental health issues requiring a supportive environment
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The purpose of health care sanctuaries is to provide a nurturing and secure setting where individuals can receive the necessary medical attention and care.
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Health care sanctuaries refer to designated areas or facilities that provide safe harbor for individuals seeking health care services without the risk of legal repercussions or penalties, particularly in the context of sensitive health information or immigration status.
Health care providers, institutions, and organizations that wish to designate themselves as health care sanctuaries must file the necessary documentation to officially register their status.
Filling out health care sanctuaries typically involves submitting a specific form that details the provider's intent, the services offered, and compliance with relevant laws and policies regarding the protection of patient information.
The purpose of health care sanctuaries is to ensure that individuals can access necessary health care services without fear of legal consequences, thereby promoting public health and safety.
Information that must be reported typically includes the name and address of the sanctuary, details of services offered, and policies related to confidentiality and non-discrimination.
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